Provider Demographics
NPI:1427086107
Name:LIEBERMAN, JOHN P (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 E ORMAN AVE
Mailing Address - Street 2:A245
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3537
Mailing Address - Country:US
Mailing Address - Phone:719-560-5930
Mailing Address - Fax:719-560-4930
Practice Address - Street 1:1925 E ORMAN AVE
Practice Address - Street 2:A245
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3537
Practice Address - Country:US
Practice Address - Phone:719-560-5930
Practice Address - Fax:719-560-4930
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40176174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15986241Medicaid
H60086Medicare UPIN
458178Medicare ID - Type Unspecified